Scarring L4-L5 right neural foramen

Tagged: Lumbar nerve root scar tissue and residual compression after surgery

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smithc4
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August 26, 2018 at 6:52 am

Post count: 3

#29014

I had a diskectomy, right sided at L4-% with a transformaminal interbody fusion L4-5 (with pedicular fixation and local bone graft and bone matrix) in July 2016. About 12 weeks after the surgery, new back pain followed by right leg pain developed. This has continued the past two years (but with myofascial release and ART treatments, have improved and I walks a lot as well as core strength workouts).

MRI’s at 6 months and 18 months post surgery both state the following: some intermediate signal tissue along the right neural foramen (L4-5), lateral disc protrusion versus scarring. Two different radiologist read the reports with same conclusion. Pain management doctor did epidural with no improvement. Conclusion is scar tissue. Nerve study shows nerves in right leg are trying top heal but……

I can not stand for more than 5 minutes or lift more than 5 lbs without setting off leg pain (back can not tolerate a full load). But if I am moving, I do pretty well. Note, I walk every day as well as do core and nerve glides.

I am in a cycle of feeling better and stronger, so I then do more which then triggers the pain, so I reduce my activity, get stronger again and then repeat the cycle (pretty much a 2 month cycle).

What are your thoughts about scar tissue on the nerve root being my cause of pain versus something else?
Should I seek out a second opinion with a surgeon?
What would you recommend as treatment options (surgical and non surgical).

Thank you.

(P.S. My son did knee research at Steadman about 6-7 years ago; great place).

Donald Corenman, MD, DC
Moderator

August 26, 2018 at 10:07 am

Post count: 8660

#29015

The first question I have is whether you have a solid fusion at that level. Having relief up to three months with return of symptoms after makes me think of pseudoarthrosis (lack of fusion).

If you have a solid fusion, the next question is whether you have any hetertopic ossification (bone formation at the wrong spots) compressing the root. Both of the above would be diagnosed by a CT scan which it appears you should consider now.

Finally, do you have significant scar compressing the root? This would be foretold by gadolinium images of the root compared to T1 images (“MRI speak”). If you have a solid fusion, but you have thick scar, a neurolysis (removal of scar and freeing of the root surgically) has about a 50% satisfaction rate post-surgery.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

smithc4
Participant

August 26, 2018 at 12:08 pm

Post count: 3

#29023

Thank you for the quick response.

My surgeon indicated I achieved a solid fusion per x rays at my last follow up visit ( ~ 13 months post op), but I have not had a CT scan.

I appreciate your providing some potential root causes for my on-going pain and next steps (i.e., a CT scan and gadolinium images).

Thank you again. This was most helpful.

P.S. Are you doing any research on stem cell use to repair degenerated disks?

Donald Corenman, MD, DC
Moderator

August 26, 2018 at 12:45 pm

Post count: 8660

#29024

Stem cells are not yet ready to repair discs. The disc is an avascular environment and any cell injected into the disc will fall to the fate of all non-oxygenated tissues. These cells certainly won’t proliferate.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

smithc4
Participant

September 25, 2018 at 6:36 am

Post count: 3

#29416

Dr. Corenman,

I was able to get a new MRI series done with and without contrast and the findings at L4/5 did confirm scar tissue but also what I guess is remaining disk material?? Lumbar fusion surgery was 26 months ago and included a disksectomy for a large extrusion.

Disc: There are postsurgical changes. There is 0.6 cm right-sided spondylotic protusion with extrusion. This does appear similar (to the previous MRI’s post surgery). As well, there is some modest enchancing scar tissue about the right L5 nerve root at right lateral recess.

Neural foraminal stenosis: There is some enhancing scar tissue at right foramen.

1) What is a spondylotic extrusion?
2) what are treatment options for this?
3) My back stays very tight like it is always braced and in protection mode; is that because of the above?
4) Does this constant “bracing” put stress on my other disks? (I have new herniations at L2/3, L3/4 and L4/5).

Thank you. Having your insights is greatly appreciated.

Donald Corenman, MD, DC
Moderator

September 25, 2018 at 8:20 am

Post count: 8660

#29417

“There is 0.6 cm right-sided spondylotic protusion with extrusion”. Spondylosis indicates bone spur. It is quite common to have a bone spur projecting out of the edge of the disc space. An “extrusion” is generally a referral to a disc herniation that has come out of the disc space.

It is possible that this compressive mass was missed during surgery or was evaluated and found to not be compressive so left alone. If however you have these continued symptoms, it would be best to get a TFESI (transforaminal epidural steroid injection) and keep track with a pain diary to determine if this level and lesion is causing some symptoms. If you gain good relief, you could be a candidate for a decompression at this level.

See https://neckandback.com/treatments/epidural-injections-and-selective-nerve-root-blocks-diagnostic-and-therapeutic/ and https://neckandback.com/treatments/pain-diary-instructions-for-spinal-injections/.

Your tight back symptom could be from the surgery, the compressive mass or the degenerative changes in the rest of your spine “I have new herniations at L2/3, L3/4 and L4/5”

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.

Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.
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Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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